Sunday, 15 April 2012

Conveyance of Mentally Disordered Patients to Hospital

An essential part of the role of the Approved Mental Health Professional is to ensure that the person they have just assessed is admitted to hospital. Having made a decision that someone needs to be admitted, whether informally or under a section of the MHA, the next step has to be to make suitable arrangements for “conveyance”, as the Act likes to call it.

However, the physical act of getting a patient to hospital once an AMHP has assessed them can be fraught with legal, ethical, logistical and practical difficulties.

The Reference Guide (para2.66) states: “A duly completed application for admission provides the authority for the applicant, or anyone authorised by the applicant [the AMHP], to take and convey the patient to the hospital named in the application”. It goes on to say (para 2.68): “Patients being taken and conveyed to hospital on the basis of an application for admission are considered to be in legal custody, and the applicant, or the person authorised by the applicant (as the case may be), may take steps accordingly to prevent the patient absconding.”

This clearly places the AMHP in a position of considerable power (and responsibility). The AMHP is responsible for ensuring that the patient reaches hospital safely, and can exert, or instruct others to exert, proportionate force or restraint if necessary. In the words of the Code of Practice (para 11.14) “Where AMHPs are the applicant, they have a professional responsibility to ensure that all the necessary arrangements are made for the patient to be conveyed to hospital.”

The Code of Practice devotes a whole chapter (Chapter 11) to “Conveyance of patients”. This chapter begins: “Patients should always be conveyed in the manner which is most likely to preserve their dignity and privacy consistent with managing any risk to their health and safety or to other people.”

Local Authorities have guidance for AMHP’s on how to convey to hospital. This guidance frequently states that all patients should ideally be transported by ambulance, although where the patient is likely to be aggressive or unpredictable, the police can be enlisted to arrange transport.

While there may be sound reasons for using an ambulance to transport a patient, the Code of Practice does not actually prescribe this. What the Code actually says is: “AMHPs should make decisions on which method of transport to use in consultation with the other professionals involved, the patient and (as appropriate) their carer, family or other supporters. The decision should be made following a risk assessment carried out on the basis of the best available information.” (para 11.16)

Factors to be taken into account include availability, distance to be travelled, the physical and mental state of the patient, the patient’s wishes, the views and wishes of the relatives, the risk of absconding or violence, and “the impact that any particular method of conveying the patient will have on the patient’s relationship with the community to which they will return”.

All this means that an ambulance may not always be the most appropriate means of transport. The CoP, para 11.21 notes: “AMHPs should not normally agree to a patient being conveyed by car unless satisfied that it would not put the patient or other people at risk of harm and that it is the most appropriate way of transporting the patient. In these circumstances there should be an escort for the patient other than the driver.”

While I would stress that all AMHP’s have to make their own decisions based on the particular circumstances of the patient, regular readers of this blog will be aware that there have been occasions when I have made a professional decision to transport the patient in my car.

Something I often find quite effective, providing I am confident that the patient is not likely to be aggressive, is to give the patient an element of choice, so that they do not feel completely overpowered by the process they have endured.

Once the decision has been made to detain the person, and the paperwork has been duly completed, I will of course inform them of the decision and of their rights to appeal against that decision. At that point, it is likely that they will continue to object, saying that they do not want to go to hospital. I will then tell them that admission is unavoidable, but that they have a choice between going in an ambulance or being taken to hospital by car.

If they choose to go by car, then I ensure that I have at least one escort with me, such as a relative, a professional colleague or an AMHP trainee, and arrange for the patient to sit in the back seat, directly behind the front passenger seat, with the escort sitting next to them.

Of course, if they decide against either choice, then they will go by ambulance. A detained patient will always end up in hospital – even if they abscond while waiting for transport to arrive.

Frequently, the patient will steadfastly maintain that they will not be taken to hospital under any circumstances. They often argue this right up until the moment when the ambulance crew enter the house – at which point they quietly pick up their overnight bag and step into the ambulance. I suppose that there is a part of them that either realises that admission is inevitable, or that recognise that it is really in their interests to be admitted.

I have said before on this blog that the arrival of someone in a uniform, whether it be a police officer or a paramedic, often seems to have a miraculous effect on a patient’s resolve and cooperation.

Where the patient still refuses to get into the ambulance, it is almost always the case that a few minutes persuasion (sometimes half an hour or more of repeating that it is unavoidable) will result in them stepping into the transport.

Sometimes the AMHP simply absenting oneself from the immediate vicinity allows the ambulance crew to assist the patient into the ambulance.

On rare occasions it may be necessary to enlist the assistance of the police. In my experience, in less than five per cent of cases does it become necessary to use any significant force to get the patient into the transport.

Having made a decision that an ambulance or police transport is required, this is far from the end of the process. AMHP’s will be very familiar with the difficulties that can arise from using the police or the ambulance service.

There are two problems that can occur at this point. One is the potential conflict between the Act’s guidance on conveyance to hospital and the Local Authority’s guidance on conveyance on the one hand, and the police and ambulance service guidelines on the other.

In practice, this means that police may be reluctant to attend in the first place, and even more reluctant to provide police transport or police assistance with transport.

The ambulance service may also be reluctant to transport a patient who has even a history of aggression, never mind be presenting as resistant on assessment.

AMHP’s can also often be frustrated by the ambulance service on the one hand insisting that police be present when risk has been identified before they will agree to attend, and the police on the other hand being reluctant to attend until the ambulance arrives. This can create logistical nightmares; some of my AMHP colleagues have found that trying to coordinate the simultaneous attendance of both the police and an ambulance can lead to many hours of delay, especially if shift changes are involved.

And if the patient has to be taken to a hospital many miles away – well, there have been times when I’ve had to wait 4-6 hours before transport has been sorted.

The other problem is the priority given to MHA admissions by ambulance services. Our local service typically gives two hours as the expected time of arrival, and even though an AMHP may regard it as of urgent necessity for a disturbed and distressed mental health patient to be admitted to hospital, the ambulance service does not give it the same priority, and ambulances on their way to the AMHP can often be diverted to what are considered more high priority calls.

Our local ambulance service has a cunning ruse to meet their targets for delays by often sending a single paramedic in a car, who then makes the assessment (surprise, surprise) that it is unsafe to transport the patient, and insisting on an ambulance with two crew – which is what you asked for and expected in the first place.

Among my AMHP colleagues, delays involving ambulances are one of the major problems encountered in discharging their duties, to such an extent that such delays are monitored.

All of which can make it very tempting for an AMHP to decide to take the patient to hospital themselves.

10 comments:

- We have no control and restraint training, thus will always ask for the police if the patient has a history of violence or we feel there is a risk of this happening. This is for both our and the patient's safety. I agree this can lead to significant delays. Another option would be to have appropriately trained NHS staff available to escort the patient, as happens on inter-facility transfers with volatile patients.

- We are usually alone in the back of the ambulance with the patient (AMHPs rarely travel). If we feel there is a risk of the patient attempting to abscond, we will again ask for assistance. It's not especially unusual to have patients attempt or succeed in leaving a moving vehicle. Many ambulances have direct access between the cab and the back, introducing another danger to ourselves, the patient and other road users.

- We have virtually no mental health training. Traditionally it consists of a few hours on the legalities of the MHA to ensure we can ascertain a section is legal before we escort the patient. Most ambulance staff pick things up about mental health, but we have little or no formal training in disease. Therefore we will lack knowledge of how to deal with these patients and common preconceptions about some MH diagnoses may prevail.

- There is, at times, an unhelpful lack of flexibility in the rule that a patient must be conveyed in an ambulance. Ambulances are full of sharp objects, loose objects and things to bash oneself on. It is very difficult and dangerous for all concerned to restrain a patient onto a bed in the back of a moving vehicle, even if handcuffed and with legs restrained. It may, at times, be far more appropriate in terms of patient safety for them to be transported in a police van designed for the purpose of safe transport of volatile people. Unfortunately policy (especially of the police) makes this very difficult at times. I fully appreciate that transport in a police van can have negative connotations, however patient and carer safety must come first.

I agree that the vast majority of patients under formal section pose no problem whatsoever - many of the observations above apply particularly to people detained under s136.

I read your response with great interest. You state: "We have virtually no mental health training. Traditionally it consists of a few hours on the legalities of the MHA to ensure we can ascertain a section is legal before we escort the patient"

Where is the law on this please? I made a Freedom of Information Act Request to the Metropolitan Police Service asking if it is necessary to obtain a Section 136 to remove forcibly a person from hospital to a place of safety who is NOT under Section 2 or 3 of the Mental Health Act?

I would be most grateful for ANY help in this matter as the MPS refuse to give me any answers, stating that I am asking for legal advice.

Hi Rosemary, I started replying to your post thinking that yes the Police can use their power under section 136 to remove a person to a place of safety then I started to have niggling doubts about whether a hospital constitues a place "to which the public has access" as it is defined in the Act. So maybe the masked amhp can help us out!? It might be helpful for you to have a look at the Mental Health Act section in wikipedia and section 136 for a definition. It is a Police power rather than a warrant so the Police do not "obtain" it as such.

I would have thought that a hospital would have in itself constituted a place of safety, so it would be difficult to justify placing someone on a S.136 who was already in a place of safety. Of course, once someone is detained under S.136 they can be moved between places of safety. Also, while the entracne and corridors of a hospital might constitute a public place, I don't think that a hospital ward, even in a general hospital, constitutes a public place. Ergo, using a S.136 to remove someone from a hospital ward does sound dubious at the least. If someone is "admitted" to a general hospital, then they cannot be detained under S.136, but could be detained under Sec.5(2) in order for a MHA assessment to take place. If the purpose is to remove someone from a hospital ward who is refusing to leave, then the police or hospital security could be used to remove them back into a puiblic place. Or does someone else out thee know better?

Hi Jess, thanks for your comments.I don't wish to criticise ambulance crews -- they're usually very helpful -- and i agree that if the patient is likely to be aggressive, then the police should accompany the ambulance or a decision should be made about using police transport.My main criticism is concerning the Ambulance Services themselves -- while a detained patient may not have the priority of a RTA, to expect a disturbed person who is likely to be in distress, to wait 2 hours or more to be taken to hospital is not really acceptable. The delay can make them even more distressed and agitated, and relatives and carers can also be very distessed by the whle process. The AMHP has to manage all this while waiting for the ambulance to arrive.

I didn't read the post as critical of ambulance crews, but the transport issue is another of the situations where the difference perspectives and priorities of the people involved (MH professionals, ambulance and police) can lead to confusion and problems. We all operate within certain constraints and come to situations with differing experiences and priorities. This is where I find reading your blog and Mental Health Cop's particularly interesting.

The priority given to transport of sectioned patients is well above my pay grade. These are usually treated as "urgents" where a vehicle should be made available within a certain time frame. This is also the case of patients being admitted to a medical hospital by a GP. Bar the sickest patients where the GP requests a 999 response, there will be a 1, 2 or 4 hour timeframe in which to supply a vehicle.

These urgent calls are naturally treated as a lower priority than 999 calls, where it is presumed there is a life threatening emergency happening.

Now in reality, many 999 calls are not life threatening, while urgent calls are to someone who is definitely physically or mentally unwell - they have been seen by a professional and judged to be unwell. On the other hand, the urgent patient has been assessed as being able to wait, while the 999 patient has had no care at all. So at times of high demand, "urgents" will wait while ambulances deal with 999 calls.

I agree that it's not desirable to wait for two hours with a mentally disturbed patient (I've done it quite a few times while trying to access MH services, but that's another discussion!).

However, many/most MH patients under section awaiting transport are not in danger of losing life or limb, so they will wait for 999 calls. A similar prioritisation process takes place for medical patients - an elderly person laying on the floor, while uncomfortable and undesirable that they stay there, is at least safe and unlikely to come to further harm.

Like yourselves, we operate in an environment of ever increasing demand at time where we have fewer and fewer resources and staff.

This does presuppose that all mental health staff are well disposed to emergency MH patients. In my experience some are but that has not always been the case for me.

I think the good people in MH care need to realise that their unprofessional colleagues can either deliberately or accidentally upset and frighten MH patients. As such it is wrong to assume that all difficult behaviour is down to bad character or mental illness. It could be the case that some MH patients are disturbed because they have been treated badly by certain MH and NHS staff.

A & E departments can have an appalling reputation for lack of sympathy.

I would agree with most of the anecdotes about conveyance best practice in this article - I have used a car on several occasions - if the back seat is wide enough I would recommend 2 escorts, one each side. And, yes, I have had several who have 'gone quietly' once the AMHP is insistent and/or stood back and let ambulance crews take charge. I abhor the excessive obsession with risk forms and the greater formality the police now expect before they will help out, as understandable as the concerns might be - what about the risk to the potential patient, relatives & public while the forms are faxed back and forth and diaries lined up etc.

The only thing I think it off in the above article / discussion, is the suggestion that an AMHP can "instruct" the police to detain and convey on their behalf. Independent legal advice obtained by the police contradicts this and there is nothing in the Act or Code which indicates that the police can be compelled to accept an AMHPs desire to delegate.

That is why local protocols are key: to define the circumstances in which police support or a police lead or a police vehicle are required, rememebring all the while that if such a local protocol does not provide LEGAL agreements about who will do what, they are null and void in terms of any professionals' duty to comply with them.

This is complicated stuff ... I don't understand for one minute why NHS MH trusts and local authorities don't work together to ensure that there is properly trained coercive capacity that isn't a police officer. Such capacity exists on wards and elsewhere, but in MHA assessments.

It is simply correct to point out that there could be some situations in which some mental health professionals would prefer the police to undertake coercion of passively resistance, non criminal, low risk patients where there is simply no duty on the police to do so. It is within this gap that problems often emerge. I work in a borough that has NO protocol on this situation - there is not agreement by any officer senior to me about what I will and won't do and how. Therefore I make it up as I go, according to my statutory responsibilities and where asked to cocerce someone who is not committing an offence or breaching the peace in circumstances where I would have to delay or decline calls to victims of crime or to the management of suspects, invariably decline.

I'm afraid I take the view, that if the NHS wants to get into the coercion business, it should prepare and train to coerce and police support will be forthcoming where it is consistent with the statutory and the constitutional role of the service.

We need to talk more, train more and develope joint protocols more - in light of LAW, not preference.

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About Me

I am an Approved Mental Health Professional working in a semi-rural area in England. I have practised under 3 Mental Health Acts, since as long ago as 1981, even before the 1983 Mental Health Act. Which makes me pretty ancient now.
This blog is designed to illuminate and explain the functions and dlimemmas of an AMHP within the Mental Health Act. It is intended to be of help to professionals and service users alike. I hope that it is both informative and entertaining.
I am also a freelance trainer, and a part time tutor on an AMHP course. I've appeared at conferences all over England and Wales. If you'd like to book me for your conference or training event just send me an email.